The other day I was playing in a tennis tournament. Normally a doubles player, I found myself playing two singles matches nearly back to back. Halfway through the match, I felt a sharp pain in the back of my thigh running after one of my opponent’s shots. After the match, I rested, took some ibuprofen, and I (should have) applied some ice. Sure enough, I had pulled a hamstring and the bruise was pretty impressive. After some time, however, I was back at it, hacking away at the ball.

My problem was real and it caused some significant pain and distress. I had a diagnosis, but that fact alone didn’t mean I was necessarily going to be prescribed opiates, be rushed into surgery, or provided disability payments.

For some strange reason, all those measured responses we see in my hamstring diagnosis seem not to register in discussions about mental illness. As far as I can tell, we are the only medical discipline (with the exception perhaps of oncology) in which ALL of our diagnoses have to be a really big deal.

The major subtext behind this debate is about drugs. Lately, there has been impassioned discussion about whether we prescribe too many psychiatric medications. This is largely a good debate to have. However, the really odd part, in my view, is that the remedy for many people is that we should just stop making psychiatric diagnoses in the first place, except in the most extreme cases. The public press and blogosphere (including many here at PT) are full of people lamenting the pathologizing of behavior that is “within normal limits.” The argument has become so extreme that experts are now sounding cautionary notes about highly valued initiatives such as universal preschool because of the worry that it will generate more cases of ADHD. What if, these folks say in alarm, ALL of us soon qualify for a mental illness at some point!

What if indeed?

Most of us have probably qualified for some kind of pulmonary or orthopedic diagnosis over the course of our life but nobody seems to be dismissing the rates of those illnesses as exaggerated. If a person presents to their internist with a slightly elevated blood pressure, what generally ensues is a diagnosis of hypertension and recommendations for diet and exercise. Can you imagine a doctor saying that they have decided to raise the new blood pressure threshold to 160/100 because too many of them were prescribing antihypertensive drugs?

Inherent in this debate is the assumption that there is some universal and correct prevalence of various psychiatric conditions that we are simply missing due to sloppy procedures. The inconvenient truth, however, is that for many diagnoses like ADHD, there simply is no absolute percentage of children who should be diagnosed, because the behaviors that constitute the disorder are dimensional. We can no better determine the true rate of ADHD than we can determine the true rate of tall people or smart people, and anyone who claims otherwise, in my opinion, is kidding themselves. This fact, however, in no way should be construed to suggest that 1) ADHD or other diagnoses are not “real” (whatever that means), or that 2) doctors can’t sometimes do a very lousy job at conducting a clinical evaluation or a research study.

In psychiatry training, we are taught that the key ingredient that separates trait from disorder is the presence or absence of impairment. That sounds great….until you realize that when it is actually measured, impairment itself is dimensional. Maybe the problem is that ubiquitous word “disorder” which, strangely enough, is only absent in describing some of the most debilitating psychiatric conditions such as schizophrenia or autism.

In our own child clinic, we use a lot of rating scales in our assessments. These instruments are standardized by sex, age, and culture. Thus, we are able to say, for example, that a child’s level of attention problems (according to a teacher or parent or self-report) is in, say, the 80th percentile compared to other kids of the same sex, age, and cultural background. That actually may be the best we can do right now. Is that ADHD? I don’t know. Could being in the 80th percentile for inattentiveness cause problems for that child? Sure, but it probably depends on lots of other things like his or her intelligence and level of structure and support at home and school, among other factors. Are medications the only thing we could offer that child? Absolutely not! Improving exercise, encouraging reading, helping him get a good night’s sleep, ensuring that the kid has a good breakfast, and counseling the parents and teachers on how to work with these behaviors may often be enough.

Another piece of well-meaning but twisted logic in my view is the idea that behaviors and feelings can’t constitute a “disorder” if the stresses that caused them were sufficiently large. This line of reasoning comes up all the time in things like depression after the death of a loved one or PTSD problems after combat under the idea that some psychological disturbance should be expected under these conditions and therefore is not disordered. But if the brain is not working quite right, then it isn’t working right, even if the event that caused that to happen is reasonable. Returning to the orthopedic example, can you imagine a surgeon coming to the ER to examine a man’s leg after being hit by a bus and saying something akin to, “Well I’m not going to diagnose a fracture or offer treatment because of course his leg should be broken after something like that.” It just seems absurd in every other field except psychiatry. If I had the guts to fight for my country in Afghanistan, and I came home with a new explosive temper and an inability to talk to my family or work a regular civilian job, I might not want to be given Thorazine, but I certainly wouldn’t want to be dismissed and sent home as being “fine.”

The arguments against broadening the limits of psychiatric diagnoses are nicely summarized in a recent blog by Dr. Allen Frances. While the motives for his concerns seem quite well-intentioned, many seem misplaced. My responses to them follow.

More diagnosis means more treatment (i.e. medications). Response: As I said before, I certainly share the concern that medications can be overused at the exclusion of other types of intervention, or no intervention at all. However, these two issues are inherently separate and if the problem is overtreatment then let’s just deal with that rather than hiding behind diagnosis. Secondly, having less severely ill people get a diagnosis and engage in treatment might just force those of us in the field to learn how to do something other than medications and traditional psychotherapy to help people.

More people will be stigmatized for being mentally ill. Response: Once again, this is a totally separate issue that should be dealt with on its own terms. Furthermore, if nearly everyone met criteria for a mental illness at some point, stigma might actually be much less, or at least be somewhat diluted. Reserving the term mental illness only for those “really sick people” certainly doesn’t do those folks any favors with regard to stigma and may only isolate them further.

It takes away needed resources from those who most need it. Response: Broadening the scope of mental health treatment to include less severely ill individuals might greatly reduce burn out of existing professionals and help the recruitment of new providers. Furthermore, the rest of the medical system has learned how to triage individuals so that those in the most need are not left to fend for themselves. We can do that too.

It paves the way for too much disability benefits. Response: Inherent in a new definition of mental illness is new scrutiny of what it means to have one. Diagnosis and disability are not synonymous terms now and certainly would not be going forward. My diagnosis of a hamstring pull didn’t provide me with disability just because it had a name.

A broadening of the definition of mental illness also fits the scientific data better. While neuroscientists have been quite successful in finding associated genes, brain regions, and neurotransmitters associated with different mental functions, we have not been nearly as successful identifying factors that help us draw a clear line between what is considered a trait and what is considered a disorder. The critics love to say things like ADHD is really JUST a child’s personality, but that little word “just” turns out imply a whole bunch of things that are wrong (see a previous post for more on that).

Obviously, for such a change in definition to be productive and not harmful, there would also need to be seismic shift on what it means to have a psychiatric diagnosis. My field of psychiatry has brought some of these concerns about over diagnosis upon ourselves, and our main diagnostic guide, the DSM, hasn’t helped us by refusing to operationalize a more dimensional perspective to diagnosis (although they acknowledged that it works that way). Psychiatrists would need to increase our tool box and replace knee-jerk tendencies to equate a psychiatric disorder with a medication. At times, we might even need to take a page from our pediatric colleagues and learn how to offer reassurance when appropriate. Some patients and parents would also need to alter the view that improving means more than taking a pill (although most get this already).

What I am really trying to say here, I think, is that scientifically there is very little to go on to help us figure out where the lower thresholds of psychiatric disorders actually exist. To deal with this reality, we can either reserve the term mental illness for those with the most extreme levels of pathology or admit that the brain, the most complicated thing that has ever existed on this planet, gets a little off track once in a while for most of us and needs a little maintenance. This maintenance does not and should not be confused with prescription medication or five times per week psychotherapy for all. There needs to be some productive middle ground between a response of, for example, “It’s ADHD and you need this medication” and “It’s not ADHD (or there is no ADHD) so go home and fend for yourself.”

This was a very thoughtful post, and in concept I completely agree. It's not an easy admission for me to make, as I have cheered on Dr. Frances' efforts to "save normal" as well, and your two perspectives appear contradictory.

I believe your views can be reconciled. Our whole field grapples uncomfortably with categorical, as opposed to dimensional, diagnosis. Dr. Frances wants to limit the damage of these categories by reining them in, while you foresee a future that doesn't rely on ham-handed labels, and where we don't treat using only blunt instruments. I hope to live in the world you describe ASAP, and I'd like to think I do my part to help it emerge. Meanwhile, we currently live in a world where your pulled hamstring (mild to moderate depression, say) is treated not with ibuprofen for a week or two, but with systemic steroids for several years. Is it any wonder that critics seek to minimize the diagnosis of hamstring pulls, or to reserve the diagnosis for very severe cases?

Of course you're right: the consequences of diagnosis shouldn't logically determine the diagnosis itself. Rein in the treatments and the disability status — whatever we decide are the real problems. If we all recognized that emotional problems admit of degrees, and that many are minor, stigma would be reduced. The thing is, larger society already knows this. Minor anxiety and slight depression are self-treated just like your pulled hamstring, or handled by non-psychiatrists who shun diagnoses completely. In contrast, we psychiatrists are usually consulted for relatively big deals. If psychiatry is to move in the direction you suggest, we need to think less categorically, and more in terms of promoting lifestyle changes akin to the first-line treatment for mild hypertension, obesity, and many other medical conditions. Having one's emotional condition rise to the level of "psychiatric" need be no big deal — but it currently is, and we made it that way. Our efforts since DSM-III in 1980 to gain legitimacy by sounding "medical" have largely backfired. Even internal medicine and general surgery don't define themselves by the severity of what they treat.

This article makes me wonder, what is the purpose of psychiatry? If it is to provide people with the emotional equivalent of a pulled hamstring with prescription drugs, why doesn't it just come out and admit that? I think Dr. Frances' point is, providing someone who has no medical diagnosis with a medical diagnosis is a lie, and this lie has become so (profitably) massive that it has undermined the credibility of psychiatry. If more of the same is somehow going to correct the massive social problems over-diagnosing and over-prescribing continue to cause, perhaps psychiatry should come up with a bunch of "non-diagnosis" diagnoses. The author's argument that diagnosing and treating more people who are less ill will combat provider fatigue and contribute to the number of new providers strikes me as especially bizarre. Reminds me of the time I, as an undergrad, walked in on a group of professors complaining bitterly about their students. The idea that everyone is "mentally ill" at some time in their lives, whatever that is supposed to mean, does nothing to alleviate the "stigma" someone with a more serious diagnosis experiences. From their psychiatrists too, apparently.

This is the the sort of reasoning from mds which causes me to avoid them for everything. If I can't treat something myself with herbs, diet, ande exercise, then death is the better option than falling into the hands of mds.

This is a great idea. Also, in response to the people warning of an overload on the health care system if the definition was broadened, people suffering from mild mental illness or injury don't actually always need to go to a doctor or health professional to be diagnosed and treated. They can still fall under the diagnosis under new criteria and treat themselves, as they already do, eg for cuts and scrapes, colds, mild depression, pms etc. Once the new definition has been made it can spread among the population and just be recognised and understood, without the need for everyone to visit a doctor.

Children "diagnosed" on the basis of rating scales produced from checklists compiled by teachers (note the internet sites which reveal that 40% to 45% of Teachers admit to bullying pupils) and by parents (no emotional psychological abuse in the homes!) Children effectively "diagnosed by the unqualified,uninformed, ignorant and abusive. And the Psychiatrists have no case to answer because someone else filled in the checklist - and they just did the sums.

Children zoning out in class is not due to "disorder" (unless biological disorder). Gifted exceptionally intelligent talented children are essentially "special needs" as defined by the Education Acts and need to be taught in a way that suits them. They zone out when under-stimulated and under challenged. Numerous gifted children are wrongly placed into remedial classes and or are misdiagnosed with ADD, ADHD, ODD, Bi-Polar, ASD, etc. (there is no biological basis for any of these "disorders" which stigmatize and destroy life - defamations - and medication is legalised poisoning)

Believe it or not some children zone out because they are emotionally psychologically abused /bullied and are unable and or unwilling to explain.

Believe it or not some children zone out because they are over tired, physically unwell, food intolerant, clothes material intolerant, noise, light, etc. intolerant

Some children hate school - after all it is designed for the 40%, the mode average - the other 60% which include our brightest, our most talented, our most evolved those with different ways of looking at the world, etc. are too diverse - it is just easier to teach the usuals - and sacrifice the brilliant.

Unfortunately 'usual' is misinterpreted to mean 'normal' and those who are not 'usual' are wrongly believed to be 'abnormal' - and so stigmatizing disorders get slapped on them.

There was an industrial revolution which changed the world. Here's hoping that there will be a psychological revolution - the floodgates to defamation charges should open up any day now - throw out all the labellers, the stigmatizers, the defamers, the poisoners, the destroyers of lives and start afresh with a compassionate view